Document Title: Woods-AJSM-Jan04.shtml
Article Title: Delayed Anterior Cruciate Ligament Reconstruction in Adolescents With Open Physes
Authors: G. William Woods, MD and Daniel P. O’Connor, PhD, PT, ATC
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: January 2004
Volume 32, pages 201-210
Keywords: pediatric ACL, delayed reconstruction, skeletal immaturity, skeletally immature, knee, risk, meniscus, activity, activity restriction, pediatric ACL reconstruction, knee degeneration due to chronic ACL deficiency.

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Comments: For skeletally immature ACL-deficient people, Woods et al. found that delaying ACL reconstruction until adulthood is a viable option if (and only if) activities are restricted to non-knee-demanding involvements (specifically, no sports which entail jumping or planting and twisting), and if (and only if) the knee is not giving way during regular daily-living activities. Failure to adhere strictly to such restrictions can be expected to engender repeated giving-way incidents, whereupon massive, cumulative, and permanent damage to the unstable knee may occur (in the form of additional damage to articular cartilage and menisci, as well as stretching-out of the secondary-restraint structures, therefore loosening of the in the knee in general). With this delayed-ACL-reconstruction concept, after the growth plates have closed, standard, anatomically-appropriate ACL reconstruction (i.e. intra-articular reconstruction with isometric graft placement) is done in the same way as it is done for people who incur ACL tears in adulthood. The authors note that children who are unwilling to adhere to activity restrictions (or whose parents are unwilling to ensure that such activity restrictions are adhered to), or who have promising athletic careers ahead of them, would be ideal candidates for physeal-sparing ACL-reconstruction techniques (along with likely a second ACL reconstruction, this time using a standard adult-style intraarticular method, once adulthood has been reached).

ABSTRACT

Background: Treatment of anterior cruciate ligament rupture in adolescents with open physes is controversial.

Hypothesis: Delaying reconstruction until the physes bridge will affect the rate of additional knee injuries.

Study Design: Case control.

Methods: The physes group was 13 adolescents with open physes whose anterior cruciate ligament reconstructions were delayed until their physes bridged. Specific types of activity were absolutely restricted during the delay. The physes groups’ rates of additional injuries, identified arthroscopically at reconstruction, were compared to rates among 116 skeletally mature adolescents. The comparison adolescents were stratified into four groups by interval from injury to reconstruction (<1 week, 1 to 6 weeks, 6 to 26 weeks, >26 weeks).

Results: The additional injury rates in the physes and four comparison groups were 46%, 50%, 47%, 43%, and 69%, respectively. Severity of additional injury, mechanism of injury, and rate of additional surgical procedures were similar among the groups.

Conclusions: There was no evidence that intentionally delayed anterior cruciate ligament reconstruction increased the rate of additional knee injuries. Delayed reconstruction is a valid treatment option for adolescents with open physes at injury. Absolute activity restriction is key to decreasing the risk of additional knee injuries.

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